MED 20 (02/25/2020)
PATIENT NAME (print)
I hereby acknowledge that Virginia Code §46.2-1053 only authorizes the application of tint to the windows and windshield of any motor vehicle up to the total levels provided in the "Sun
Shading Allowances" table above. I also understand that any recommendation for darker tint will subject the vehicle and its owner to a Virginia Code violation. I further certify and affirm
that all information presented in this form is true and correct, that any documents I have presented to DMV are genuine, and that the information included in all supporting documentation
is true and accurate. I make this certification and affirmation under penalty of perjury and I understand that knowingly making a false statement or representation on this form is a
criminal violation.
CITY
Based on my examination, vehicle sun-shading is necessary for my patient's health. If yes, describe the medical condition that requires the use of sun-shading.
BUSINESS ADDRESS
TELEPHONE NUMBER
( )
STATE ZIP CODE
FAX NUMBER
( )
Yes
No
LICENSE NUMBER
MEDICAL PROVIDER NAME (print)
MEDICAL PROVIDER SIGNATURE
DATE (mm/dd/yyyy)
MEDICAL PROVIDER CERTIFICATION
CHECK BOX THAT APPLIES:
PHYSICIAN
PHYSICIAN ASSISTANT
NURSE PRACTITIONER OPHTHALMOLOGIST
OPTOMETRIST
PATIENT BIRTHDATE (mm/dd/yyyy)
Year Make Model Title Number Identification Number (VIN) License Plate Number
Identify each vehicle to be equipped with sun-shading material (List additional vehicles on reverse.)
VEHICLE INFORMATION
MAILING ADDRESS (if different from above)
CITY STATE ZIP CODE
I hereby acknowledge that Virginia Code §46.2-1053 only authorizes me to apply tint to the windows and windshield of my motor vehicle(s) up to the total levels provided in the "Sun
Shading Allowances" table above. I also understand that the law does not authorize me to have darker tinting applied, even with a medical provider's recommendation. I further certify
and affirm that all information presented in this form is true and correct, that any documents I have presented to DMV are genuine, and that the information included in all supporting
documentation is true and accurate. I make this certification and affirmation under penalty of perjury and I understand that knowingly making a false statement or representation on this
form is a criminal violation.
APPLICANT/LEGAL GUARDIAN'S SIGNATURE
VEHICLE OWNER CERTIFICATION
DATE (mm/dd/yyyy)
RESIDENCE/HOME ADDRESS
DAYTIME TELEPHONE NUMBER
( )
CITY STATE ZIP CODE
VEHICLE OWNER INFORMATION
VEHICLE OWNER NAME (print) DMV CUSTOMER NUMBER
To be eligible for sun-shading, as provided in Va Code §§ 46.2-1052 and 46.2-1053, the vehicle must be equipped with both left and right outside mirrors.
SUN-SHADING ALLOWANCES INFORMATION
Total Percentage of Light Transmittance Allowed
Vehicle Window
Without Medical Authorization
Regular Passenger Vehicles Multi-Use Passenger Vehicles
With Medical Authorization
Windshield No sun-shading allowed No sun-shading allowed
35% - upper 5 inches to AS-1 line
70% windshield
Front Side Windows 50% 50%
35%
Rear Side Windows 35% No limitations
35%
Rear Window 35% No limitations
35%
CHECK ONE:
APPLICATION TYPE
New Application (apply for sun-shading medical authorization) Subsequent Application (add vehicle(s) to existing sun-shading medical authorization)
Sun-Shading Medical
Authorization Application
Purpose: Use this form to apply for a sun-shading medical authorization or to add additional vehicle(s) to an existing sun-shading medical authorization.
Instructions: Complete this form in its entirety and return to any DMV customer service center, mail to DMV at the address above, or fax to (804) 367-1384.
NOTE: Medical Provider Certification is required for new applications only - not subsequent applications.
DMV USE ONLY
LOG NUMBER
